[The management of neurosurgical patients operated in the seated position].
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Anesthesia↗
Biomedical subjects
M Fischler
Publications and source records attributed to M Fischler.
Transtracheal high frequency jet ventilation for endoscopic airway surgery: a multicentre study.
Serious complications during high frequency jet ventilation (HFJV) are rare and have been documented in animals and in case reports or short series of patients with a difficult airway. We report complications of transtracheal HFFJV in a prospective multicentre study of 643 patients having laryngoscopy or laryngeal laser surgery. A transtracheal catheter could not be inserted in two patients (0.3%). Subcutaneous emphysema (8.4%) was more frequent after multiple tracheal punctures. There were seven pneumothoraces (1%), two after laser damage to the injector, one after difficult laryngoscopy, four with no clear cause. Arterial desaturation of oxygen was more frequent during laser surgery and in overweight patients. Transtracheal ventilation from a ventilator with an automatic cut-off device is a reliable method for experienced users. Control of airway pressure does not prevent a low frequency of pneumothorax.
Adolescent↗
A randomized, double-blinded comparison of intrathecal morphine, sufentanil and their combination versus IV morphine patient-controlled analgesia for postthoracotomy pain.
UNLABELLED: We compared the analgesic effect of lumbar intrathecal (IT) 0.5 mg morphine (Group M, n = 10), 50 microg sufentanil (Group S, n = 10), and their combination (Group S-M, n = 10) given before general anesthesia and patient-controlled analgesia with IV morphine (Group C, n = 19) in a randomized, double-blinded study performed in patients undergoing thoracotomy. Pain visual analog scale (VAS) and morphine consumption were assessed for 24 h. In Group S-M the number of patients initially titrated with IV morphine was less than in group C (30 vs 84%, P < 0.05). Morphine requirement was higher in Group C (71 +/- 30 mg) than in Groups S (46 +/- 34 mg, P < 0.05), M (38 +/- 31 mg, P < 0.05) and S-M (23 +/- 16 mg, P < 0.01). VAS scores were significantly decreased during the first 0-11 postoperative h at rest and during the first 0-8 postoperative h on coughing in Groups M and S-M rather than in Group C. The incidence of side effects was infrequent except for urinary retention. Preoperative IT morphine or combined sufentanil and morphine could be given as a booster to achieve rapidly effective analgesia in the immediate postoperative period. IMPLICATIONS: As compared with IV patient-controlled analgesia, intrathecal morphine or combined sufentanil and morphine provided superior postoperative pain relief both at rest (11 h) and on coughing (8 h) than did IV patient-controlled analgesia morphine alone. IV morphine requirement was decreased during the first postoperative day after posterolateral thoracotomy.
Analgesia, Patient-Controlled↗
Angiotensin converting enzyme inhibitor induced hyperkalaemic paralysis.
Secondary hyperkalaemic paralysis is a rare condition often mimicking the Guillain-Barré syndrome. There have been a few case reports of hyperkalaemia caused by renal failure, trauma, and drugs where the presentation has been with muscle weakness. A case of hyperkalaemic paralysis caused by an angiotensin converting enzyme inhibitor is reported.
Aged↗
[Apical hypertrophic cardiomyopathy: a pitfall in preoperative electrocardiography].
We submit two case reports of apical hypertrophic cardiomyopathy knowing that the diagnosis of one of them has been very intricate at the time of preoperative evaluation. This disease, unfrequent besides Japan, is either silent or induces cardio-vascular symptoms which are often poorly typical. The diagnosis relies on echocardiography using a high frequency probe to reveal an apical hypertrophy. In one case, a coronarography has been necessary since echocardiography failed to establish a diagnosis. Anaesthestic perioperative management should take into account the risk of apical ischaemia and the impairment of the left ventricle compliance.
Aged↗
Assessment of systematic use of intraoperative transesophageal echocardiography during cardiac surgery in adults: a prospective study of 203 patients.
OBJECTIVE: To determine the usefulness of systematic intraoperative transesophageal echocardiography in a cardiac surgical unit. DESIGN: Open prospective observational survey. SETTING: University Hospital. PARTICIPANTS: Consecutive adult patients (n = 203) undergoing elective or urgent cardiac operations. MEASUREMENTS AND MAIN RESULTS: Pre-cardiopulmonary bypass imaging yielded unsuspected findings in 26 patients (12.8%) and changed the planned surgery in 22 patients (10.8%). Transesophageal echocardiography modified the diagnosis in eight patients (17%) operated on for mitral valvulopathy, in seven patients (15.5%) with aortic valvular disease, in four patients (4.6%) with coronary artery disease, in five patients operated on for thoracic aorta diseases regardless of their localization (18.5%), and in two miscellaneous cases. On the basis of the data obtained from the transesophageal echocardiography carried out at the end of cardiopulmonary bypass, an immediate reintervention was required in five cases (2.5%). CONCLUSIONS: It is concluded that systematic intraoperative transesophageal echocardiography significantly affected decision making in this cardiac surgical unit. Its routine use in all cardiac surgical patients is recommended.
Adult↗
Extreme pulmonary hypertension and anesthesia induction.
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Anesthesia↗
Pulmonary air trapping during two-lung and one-lung ventilation.
OBJECTIVE: Evaluation of the magnitude of pulmonary air trapping during routine thoracic surgery and single-lung transplantation. DESIGN: Prospective study on consecutive patients. SETTING: Single institution, university hospital. PARTICIPANTS: Sixteen patients with no or moderate obstructive lung disease undergoing routine thoracic surgery (group 1), six patients with severe emphysema (group 2), and six patients with severe fibrosis (group 3) undergoing single-lung transplantation. INTERVENTIONS: Occlusion maneuver timed at the end of expiration to measure auto-positive end-expiratory pressure (auto-PEEP) and trapped volume (delta FRC). The maneuver was performed during two-lung ventilation in supine (2LV supine) and lateral decubitus (2LV lateral) positions and during one-lung ventilation (OLV) in lateral decubitus position. At the same time, airway pressures and PaO2 measurements were performed. MEASUREMENTS AND MAIN RESULTS: In group 1, consistent values of auto-PEEP and delta FRC occurred only during OLV: 4.8 +/- 2.5 cm H2O and 109 +/- 61 mL (mean +/- standard deviation). In group 2, auto-PEEP and delta FRC values were 11.7 +/- 6.9 cm H2O and 355 +/- 125 mL during 2LV supine, 8.8 +/- 5.7 cm H2O and 320 +/- 122 mL during 2LV lateral, and 15.9 +/- 3.9 cm H2O and 284 +/- 45 mL during OLV. In group 3, pulmonary air trapping was low. For the three groups together, auto-PEEP and delta FRC (p < 0.0001) related inversely to the ratio of forced expired volume in 1 second (FEV1) to forced vital capacity (FVC) expressed in percent (FEV1/FVC%) during OLV. In contrast, there was no correlation between PaO2 and auto-PEEP or delta FRC. CONCLUSION: Pulmonary air trapping must be suspected in patients with no or moderate obstructive lung disease during OLV and in those with severe obstructive disease as soon as 2LV is initiated.
Adult↗
Haemodynamic assessment of hypovolaemia under general anaesthesia in pigs submitted to graded haemorrhage and retransfusion.
We have compared the value of different variables used in the assessment of blood loss during progressive hypovolaemia and resuscitation under general anaesthesia in anaesthetized pigs. We measured mean arterial pressure (MAP), pulmonary capillary wedge pressure (PCWP), the negative component of the systolic arterial pressure variation (delta Down) and left ventricular end-diastolic area (LVEDa) using echocardiography. Blood was progressively withdrawn (up to 35 ml kg-1 in seven steps) and then reinfused after the same pattern. Regression coefficient (r) and normalized slope (nS) of the regression relationship between each variable and amount of blood loss were determined. The difference between the withdrawal and reinfusion curves was assessed by the area between the curves. We also estimated the minimal loss of blood volume which induced significant changes in each variable compared with that under control conditions during withdrawal of blood (minWBV) and maximal loss in blood volume which induced no significant changes in a variable compared with control conditions during retransfusion (maxRBV). During haemorrhage, MAP decreased (from mean 74 (SD 9) to 31 (5) mm Hg; P < 0.001), delta Down increased (from 1.2 (1.4) to 11.4 (4.2) mm Hg; P < 0.001), PCWP decreased (from 6.2 (2.1) to 0.3 (1.0) mm Hg; P < 0.001) and LVEDa decreased (from 13.8 (2.0) to 5.1 (2.0) cm2; P < 0.01). The highest r values were obtained with MAP and LVEDa, and the highest nS value with delta Down. The least difference between withdrawal and reinfusion was with LVEDa, the lowest values of minWBV were with PCWP and LVEDa, and the highest value of maxRBV was obtained with PCWP. During progressive haemorrhage under general anaesthesia, LVEDa was an accurate variable for assessment of blood volume loss, delta Down contributed no further information compared with MAP, and PCWP was the most reliable variable for assessing return to baseline blood volume.
Anesthesia, General↗
Improving oxygenation during bronchopulmonary lavage using nitric oxide inhalation and almitrine infusion.
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Administration, Inhalation↗
[Specificity of difficult intubation in cervico-facial oncology].
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Adult↗
[Early perioperative mortality in a multidisciplinary hospital].
OBJECTIVE: To evaluate the incidence and the causes of early intra- and postoperative deaths in a multidisciplinary hospital. STUDY DESIGN: Retrospective survey. PATIENTS: All patients receiving an anaesthetic between 1992 and 1995. METHODS: Analysis of all deaths occurring during anaesthesia and in the subsequent 24 hours. Demographic data (age, gender) and medical data (ASA physical class, type of surgery and degree of emergency) were recorded. The contribution of anaesthesia, surgery or patient disease to fatal outcome was analysed. RESULTS: The analysis included 52,654 patients who underwent either general anaesthesia or epidural analgesia. Perioperative mortality (n = 170) was 1/310 patients (0.32%). The risk factors for mortality (multivariate analysis) were: age > 64 years (odds-ratio [OR] 4.8), ASA class > or = 3 (OR 16.6), emergency surgery (OR 3.6), duration of surgery > 115 minutes (OR 37.4). Fifty percent of deaths (95% confidence interval [CI] = 42-58) were related to patient's underlying diseases and 29% to surgery (CI 95% = 22-36). The percentage of deaths linked to anaesthesia was 17.6% (CI 95% = 11.9-23.3, 1/1,755), consisting of 8.2% (CI 95% = 4.1-9.3, 1/3,761) totally due to anaesthesia and 9.4% (CI 95% = 5-13.8, 1/3,291) only partially. The main aetiologies of the deaths linked to anaesthesia were a mismanagement of severe haemorrhages (30%), respiratory complications (23%) or cardiac complications (23%). The mismanagement of an intraoperative critical situation (46%) and a mistake in the post-operative care (33%) were the main causes. DISCUSSION: In this survey, mortality due to anaesthesia was higher than the rates reported in other studies. Human error remained the main cause.
Adolescent↗
The effect of adding a minidose of clonidine to intrathecal sufentanil for labor analgesia.
BACKGROUND: Preliminary studies have suggested that the addition of clonidine to intrathecal sufentanil prolongs analgesia without producing motor blockade. METHODS: Fifty-three nulliparous women in painful labor were included in this prospective, randomized, double-blinded study. Parturients at 2- to 5-cm cervical dilation received either 5 microg sufentanil plus 30 microg clonidine or 5 microg sufentanil intrathecally, followed by 5 mg bupivacaine epidurally. The primary outcome was time until first request for additional analgesia. Visual analog pain scores, sensory changes, blood pressure, heart rate, ephedrine requirements, motor blockade, sedation, pruritus, and nausea were also recorded. RESULTS: All parturients but one had effective analgesia in both groups, with similar sensory levels never exceeding T2. The duration (mean +/- SD) of analgesia was longer in the sufentanil-clonidine group: 125+/-46 versus 97+/-30 min (P = 0.007). The incidence of hypotension and the ephedrine requirements (median with range) were higher in the sufentanil-clonidine group: 63% versus 12% (P < 0.001) and 7.5 mg [range, 0-25.5 mg] versus 0 mg [range, 0-6 mg] (P < 0.0001). The incidence of fetal heart rate abnormalities during the first 30 min after intrathecal injection was similar in both groups (17% vs. 19%). No parturient had motor blockade. CONCLUSIONS: The addition of 30 microg clonidine to 5 microg intrathecal sufentanil extended the duration of labor analgesia without producing motor blockade. However, as previously reported with 100-200 microg clonidine, the incidence of hypotension and the ephedrine requirements were also increased, even when 30 microg clonidine only was added.
Adrenergic alpha-Agonists↗
[Explanatory factors for length of stay in the postoperative intensive care unit].
OBJECTIVES: Because of the increasing role of post-anaesthesia care in anaesthetic activity, the explicative value of various factors on post-anaesthesia length of stay (POLS) was tested. STUDY DESIGN: Retrospective study. PATIENTS: Population of 38,655 patients admitted to the post-anaesthesia care unit (PACU) between 1990 and 1994. METHOD: Multivariate analysis (semiparametric Cox model) of POLS. RESULTS: Overall 71% of the patients stayed less than four hours in PACU. Average POLS did not vary with years. Eleven variables were related to POLS, with an odds-ratio (OR) between 0.75 and 0.77 (negative link) or between 1.22 and 2.77 (positive link). A comparison of the OR for years 1990 to 1994 indicated major variations for the following three variables: neurosurgery, mechanical ventilation in PACU, low occupancy rate in the PACU at the time of discharge. CONCLUSION: POLS are linked with various factors whose changes in explicative value can be analysed chronologically. However, other methods remain necessary in order to evaluate the impact of organisational modifications, as the introduction of objective criteria for discharge.
Anesthesia↗
Increased intraperitoneal pressure up to 15 mm Hg does not reliably induce haemodynamic changes in pigs.
Haemodynamic alterations occur consistently with laparoscopic surgery in humans. These haemodynamic changes have never been reproduced in an animal model without additional potentiating factors. As these alterations may be deleterious in some patients and as the cause is only partly understood, we have used an animal model to study these changes. Pneumoperitoneum with intraperitoneal pressures of up to 15 mm Hg were produced in pigs, in the same way as for laparoscopic surgery in humans. Arterial pressure, cardiac output, pulmonary arterial pressure and systemic arterial resistance were assessed at baseline and after pneumoperitoneum had been produced. Intraperitoneal pressures of up to 15 mm Hg were not associated with consistent circulatory changes and we conclude that haemodynamic changes associated with laparoscopic surgery are dependent on species.
Animals↗
The effects of inhaled nitric oxide and its combination with intravenous almitrine on Pao2 during one-lung ventilation in patients undergoing thoracoscopic procedures.
UNLABELLED: The aim of this study was to assess whether hypoxemia during one-lung ventilation (OLV) can be prevented by inhaled nitric oxide (NO) (Part I) or by its combination with intravenous (IV) almitrine (Part II) in 40 patients undergoing thoracoscopic procedures. In Part I, 20 patients were divided into two groups: one received O2 (Group 1) and one received O2/NO (Group 2). In Part II, 20 patients were divided into two groups: one received O2 (Group 3) and one received O2/NO/almitrine (Group 4). In Groups 2 and 4, NO (20 ppm) was administered during the entire period of OLV, and almitrine was continuously infused (16 microg x kg(-1) x min[-1]) in Group 4. Arterial blood gases were measured during two-lung ventilation with patients in the supine position, after positioning in the lateral decubitus position, and then every 5 min for a 30-min period during OLV. During OLV, Pao2 values decreased similarly in Groups 1 and 2. After 30 min of OLV, the mean Pao2 values in Groups 1 and 2 were 132 +/- 14 mm Hg (mean +/- sem) and 149 +/- 27 mm Hg (not significant [NS]), and the Pao2 value was less than 100 mm Hg in four patients in Group 1 and five patients in Group 2. Pao2 values were greater in Group 4 than in Group 3 after 15 and 30 min of OLV. After 30 min of OLV, the mean Pao2 values were 146 +/- 16 mm Hg in Group 3 and 408 +/- 33 mm Hg in Group 4 (P < 0.001). Pao2 was less than 100 mm Hg during OLV (NS) in four patients in Group 3 and in no patient in Group 4. We conclude that NO inhalation alone has no effect on Pao2 evolution during OLV, although its combination with IV almitrine limits the decrease of Pao2 during OLV. This beneficial effect of NO/almitrine could be attributed to an improvement in ventilation-perfusion relationships. IMPLICATIONS: Decrease in oxygenation during one-lung ventilation is quite common. Our study showed that inhaled nitric oxide alone did not influence Pao2 evolution. We then tried adding intravenous almitrine to nitric oxide with amazingly good results on Pao2. This nonventilatory technique should be of great use during special thoracic acts, such as thoracoscopic procedures.
Adult↗
Intraoperative transesophageal echocardiographic assessment of vascular anastomoses in lung transplantation. A report on 18 cases.
BACKGROUND: In patients after lung transplantation, dysfunction of pulmonary venous and artery anastomoses leading to reoperation is described. METHODS AND RESULTS: Pulmonary artery and vein anastomoses were evaluated intraoperatively by monoplane transesophageal echocardiography (TEE) in 18 patients undergoing lung transplantation (nine right, five left single lung transplantations, and four bilateral transplantations). All 13 right pulmonary artery anastomoses and all 22 pulmonary vein anastomoses could be visualized by TEE. None of the nine left pulmonary anastomoses could be visualized. Of the 13 right pulmonary anastomoses, 12 were considered normal, their diameter ranging from 1 to 1.7 cm (mean, 1.26 +/- 0.24 cm). A moderate stenosis of one pulmonary artery anastomosis was identified but did not require reoperation. Of the 22 pulmonary vein anastomoses, 16 were considered normal, their diameter being > 0.5 cm and the peak systolic flow velocity < or = 1 m/s at the location of the anastomoses. In five cases, the anastomoses were not considered normal, but reoperation was not indicated. In one case, a severe stenosis of pulmonary vein associated with graft dysfunction led to an early reoperation. CONCLUSION: Intraoperative TEE during lung transplantation contributes to the immediate evaluation of pulmonary vein and right pulmonary artery anastomoses and allows immediate surgical correction. Further investigations are necessary to establish threshold values requiring reoperation.
Adolescent↗
[Apropos of blood patch after thoracic epidural anesthesia].
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Anesthesia, Epidural↗